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Request for Reimbursement

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Request for Reimbursement
Request for Reimbursement
Use this form for reimbursements ONLY; it is not intended for equipment purchases.
You are encouraged to use your procurement card.
Do not use to pay invoices. For pre-approved expenses only.
Request must be accompanied by original receipts and proof of payment.
DO NOT USE FOR THE FOLLOWING EXPENSES. FOR THESE EXPENSES USE THE FORM SPECIFIED:
Travel - Statement of Conference Expense
Mileage - Mileage Expense Claim Form
All Expenses under $100 - Petty Cash Fund Reimbursement Request
Contract or Consulting Services - Authorization for Payment of Services (Independent Contractor Agreement)
Payable to: Requestor's Name
College
Extension
Division
Social Security Number or ID
Requestor's Signature
Date
Administrator's Signature
Date
Budget Officer's Signature
Date
List each receipt separately
Purchase Date
Item Description
For Tuition Reimbursement:
Please submit final grading within 30 days of
completion to your budget officer at your campus.
Fund No. Org No. Acct No. Program
Total Approved for Payment:
Amount
$0.00
Submit this form with original receipts to District A/P Dept.
Retain copies of your receipts until re-imbursed
rev. 1/16
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